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“There is one aspect to medicine that we have too easily given up on—time. Time allows for the full range of information to be collected, weighed, reviewed, analyzed, refined, and finally agreed on. Medicine desperately needs to create a better temporal space for the patient and doctor to work in. My final hypothesis is that doctors who practice in a time-rich environment provide better care—and more carefully thought through decisions—than doctors who do not. The one “treatment” doctors can, but rarely do, offer a patient is their time. One could design a clinical trial to test this theory. Patients with chronic disease could take part in a study in which they are randomized to receive care either in a time-poor setting (the current standard) or in time-rich setting. The benefit, if there truly was one could easily be measured. (

Horton, Richard. Health Wars. On the Global Front Lines of Modern Medicine. New York: New York Review of Books, 2003:61

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There is growing concern that the internet might become a significant source of tobacco products for minors. Recent studies suggest that 2–3% adolescent smokers were purchasing cigarettes through the internet. Minors appear to have easy access to tobacco via the internet because most vendors do not have adequate age verification methods. Improved regulation of sales of cigarettes on the internet may be necessary to prevent minors from purchasing them in this way. (

JAMA2003;20:1356–9

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Female survivors of Hodgkin’s disease have an increased risk of breast cancer. The factors responsible for this increased risk are not yet defined. A study from the Netherlands suggests that the breast cancer risk increases with increasing radiation doses used in the treatment of Hodgkin’s disease. There is a substantial risk reduction associated with chemotherapy. (

Safety devices for children travelling in automobiles have improved dramatically over the past few years. Nevertheless, motor vehicle accidents continue to be a major cause of childhood trauma and death. Ejection from the car is common among fatally injured children (29%). Shoulder straps alone, as found in the overhead shield child seats that face forward in the automobile, may not be adequate to prevent the ejection of toddlers from child safety seats, especially during rollovers. (

Chronic pain associated with osteoarthritis of the knee may be treated with systemic anti-inflammatories, topical anti-inflammatories, and intra-articular injections of corticosteroid or hyaluronic acid. In a study from Seattle, WA, patients with osteoarthritis of the knee underwent either injections of corticosteroids or hyaluronic acid. There were no differences with respect to pain relief for improved functions at 6 months of follow up with these two therapies. Moreover, women demonstrated a significantly less positive response to either therapy than did men. The reason for this sex difference is not yet known. (

Osteoporosis is a major cause of disability and excessive mortality in older women. Oestrogen therapy has been used for treatment in prevention for osteoporosis. However, recent studies have emphasised the significant side effects associated with this therapy. A study from the University of Connecticut investigated whether ultra low doses of oestrogen were effective in maintaining bone mineral density and reducing bone turnover while reducing the adverse side effects associated with oestrogen replacement therapy. In this study bone density of the hips, spine, and total body was increased in those women on very low dose 17β-oestradiol replacement therapy. There were minimal adverse side effects. The authors suggest that future studies need to be completed before widespread use of ultra low dose oestrogens can be advocated in the prevention and treatment of osteoporosis. (

Familial hemiplegic migraine is one of the unusual forms of complicated migraine. It is inherited as an autosomal dominant disorder. Missense mutations in the chromosome of 19CACMA1A calcium channel gene have been found in at least half of affected families. The T66M mutation seems to be the most frequent mutation in these families. Nevertheless, there is remarkable clinical heterogeneity among families with the T66M mutation and familial hemiplegic migraine. (

The adverse affects of elevated serum cholesterol on cerebral blood vessels is well documented. Whether or not a similar adverse effect on the development of Alzheimer’s disease is related to elevated cholesterol levels is unclear. In a study from Boston more than 5000 subjects from the Framingham study original cohort were evaluated. In this study neither baseline nor long term average serum total cholesterol levels were associated with the risk or incidence of Alzheimer’s disease. (

The World Health Organization estimates that 5–7% of all drugs sold in the United States have been tampered with, mislabelled, or were otherwise fraudulent. The problem is probably much more severe outside the United States especially in developing countries. According to the European Federation of Pharmaceutical Industries and Associations, up to half of all drugs sold in Pakistan, Nigeria, and China may be overt counterfeits. A task force for the FDA is expected to advocate some type of tracking technology for shipment of medications to try to reduce this problem. (

JAMA2003;290:1016

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Controversy continues about the possibility that vaccinations may be related to the increased frequency of autism. Thiomersal (thimerosal), an organic compound that contains ethyl mercury, has been widely used since the 1930s as a preservative in certain vaccines. It has been suggested that the mercury component of vaccines may be toxic to the developing child. However, in a study from Denmark of all children born from 1 January 1990 to 31 December 1996 the risk of autism and other autistic spectrum disorders did not differ significantly between children vaccinated with thiomersal-containing vaccine and those vaccinated with thiomersal-free vaccine. (

The use of non-steroidal anti-inflammatory drugs has been suggested to have a protective effect on preventing Alzheimer’s disease. In a systematic review and meta-analysis of observational studies published between 1966 and October 2002 investigators found that non-steroidal anti-inflammatories did offer some protection against the development of Alzheimer’s disease. However, the appropriate dose and duration of the drug required for the protective effects is not clear from the data published thus far. (

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